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Audit & Data

Clinical audit is a quality improvement process to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.

All practising ophthalmic clinicians should be actively involved in clinical audit of their own and their service’s care.

Clinical audit measures whether healthcare is adhering to recognised best practice standards and provides a mechanism for change and action where improvement is required. All practising ophthalmic clinicians should be actively involved in clinical audit of their own and their service’s care.

Active audits

The College manages the  National Ophthalmology Database (NOD) Audit as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) and involvement in this is part of the College Quality Standard for all providers of NHS cataract services. NOD has expanded to include age related macular degeneration.

The RCOphth has developed national clinical datasets which support risk based clinical audit and assessment of patient outcomes in various aspects of ophthalmic practice.

Defining a clinical data set

A clinical data set is an operational standard which is a list of well defined variables relevant to clinical activity. The information must be unambiguous and should not contradict existing standards, so for example date of birth is recorded in a standard manner already established in the NHS data dictionary. More ‘specialist variables’ e.g. things to do with biometry for example which currently do not exist in the data dictionary, must be defined de novo in the cataract data set.

The benefits about of routine data collection

The data set is not a ‘form’ to be filled out; it refers to the variables to be collected and the format which they should take. It is expected that the data will be collected as part of routine care and other benefits such as audit and revalidation will be entirely secondary. It is about standardisation of data content, meaning and format for electronic use. Once approved, EMR systems will need to conform to this standard.

Not every item of data will be mandatory. This exercise is not being done for the purposes of revalidation but should help with that process as a secondary benefit, predominantly when EMR systems are in place. If electronically collected data all have the same meaning regardless of locality and EMR system being used then this will ease the burden of collection of comparable cross boundary data and the burden upon doctors individually.

Case mix adjustment

This type of working will also allow case mix adjustment of outcomes to ensure that comparisons are as fair as possible. Without standardised electronic collection of data this level of refinement (fairness) would not be possible. A practical benefit of case mix adjustment would be that surgeons would not feel under pressure to behave in a risk averse manner and avoid high risk cases in the interests of ‘maintaining a good average’.

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